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KIFFOAnalvtical UC SRG#: Project ID RecetveR SAMPLE RECEIPT CHECKLIST r Inill O Date: Q S-0 y I V 0 8 1 �; y, .54v Courier Method of of Rece t:'® Courier ❑ Over-the-counter ❑ Over-the-counter U Shipper U Shipper'® COInspection ❑ No Is COC present? zYes Intact []Broken ❑ Not present KN/A Custody seals on shipping container? Is COC Signed by Relinquisher? fizyes ❑ No Dated? 0 Yes E] No Is sampler name legibly indicated on COC? Yes XYes ❑ No ❑ No Is analysis or hold requested for all samples ayes ❑ No Is the turnaround time indicated on COC? Is COC free of whiteout and uninitialed cross -outs? ❑ Yes ❑ No, Whiteout §�,No, Cross -outs Sample Inspection Coolant Present: (Yes ❑ No (includes water (ISO Lf `� ❑ N/A Temperature °C q, -I-Therm. 1D# � < s Initial�]f� Date/Time Are there custody seals on sample containers? El Intact ❑ Broken Not present Do containers match COC? Yes ❑ No ❑ No, COC lists absent sample(s) ❑ No, Extra sample(s) present Are there samples matrices other than soil, water, air or carbon? ❑ Yes WNo Are any sample containers broken, leaking or damaged? ❑ Yes No Are preservatives indicated? ❑ Yes, on sample containers ❑ Yes, on COC E] Ne indicated �A Are preservatives correct for analyses requested? ❑ Yes L1 No Are samples within holding time for analyses requested? to Yes ❑ No Are the correct sample containers used for the analyses requested? V9 Yes ❑ No Is there sufficient sample to perform testing? MYes ❑ No No Does any sample contain product, have strong odor or are otherwise suspected to be hot? ❑ Yes Receipt Details Matrix D Container type > -eQA`� - # of containers received_ Matrix Container type # of containers received Matrix Container type # of lontainers received Date and Time Sample Put into Temp Storage Date: OI Time: 3.3— uickio Are the Sample ID's indicated: ❑ On COC ❑ On sample container(s)On Both ❑ Not indicated If Sample ID's are listed on both COC and containers, do they all match? Yes (N No ❑ N/A Is the Project ID indicated: ❑ On COC ❑ On sample container(s) K On Both ❑ Not indicated If project ID is listed on both COC and containers, do they all match? 9 -Yes LJ No ❑ N/A Are the sample collection dates indicated: ❑ On COC ❑ On sample container(s) /�20n Both ❑ Not indicated If collection dates are listed on both COC and containers, do they all match? Yes ❑ No ❑ N/A Are the sample collection times indicated: ❑ On COC ❑ On sample container(s) On Both ❑ Not indicated If collection times are listed on both COC and containers, do they all match? ZYes ❑ No ❑ N/A COMMENTS: 0Ao1d ed\sampreclFotmslSample Receipt Checklist rev 051409.doc Page 13 of 13